Patient Forms

Do you like saving time? We like to save your time, too!! So we have created an easy way for you to use our downloadable forms. Just download, fill out, and bring to your next appointment. Or, if you’d rather fill out the form online, please do so below.

Patient Registration Form

If you are human, leave this field blank.

Patient Information

First Name
*

Last Name
*

Middle Initial

Street Address
*

City
*

State
*

Zip Code
*

Birth Date
*

Social Security Number
*

Gender

Male

Female

Marital Status

Single

Married

Separated

Divorced

Widowed

Home Phone

Work Phone

Cell Phone

How would you prefer to be contacted for appointment confirmation?

Email

Text

Phone

Email

Whom may we thank for referring you to our office?

Relationship to responsible party

Employer

Emergency Information

Peron to contact in an emergency

Relationship to patient

Home Phone

Work Phone

Cell phone

Responsible Party

Last Name
*

First Name
*

Middle Initial

Street Address
*

City
*

State
*

Zip Code
*

Birth Date
*

Social Security Number
*

Gender

Male

Female

Marital Status

Single

Married

Separated

Divorced

Widowed

Home Phone

Work Phone

Cell Phone

Employer

Spouse's Name

Spouse's Birth Date

Spouse's Employer

Spouse's Work Phone

Insurance Information

Primary Dental Insurance

Policy Holder's Name
*

Employer
*

Relationship to patient
*

Group Number

Subscriber Number

Policy Holder's Birth Date

Insurance Company
*

Group Number

Insured's Address

Do you have additional dental insurance?

Yes

No

Secondary Dental Insurance

Policy Holder's Name

Employer

Relationship to patient

Group Number

Subscriber Number

Policy Holder's Birth Date

Insurance Company

Group Number

Insured's Address

Do you have additional dental insurance?

Yes

No

Dental Information

Please mark your responses to the following questions

Do your gums bleed when you brush or floss?

Yes

No

DK

Are your teeth sensitive cold, hot, sweets, or pressure?

Yes

No

DK

Does food or floss catch between your teeth?

Yes

No

DK

Is your mouth dry?

Yes

No

DK

Have you had any periodontal (gum) treatments?

Yes

No

DK

Have you ever had orthodontic (braces) treatment?

Yes

No

DK

Have you had any problems associated with previous dental treatment?

Yes

No

DK

Is your home water supply fluoridated?

Yes

No

DK

Do You drink bottled or filtered water?

Yes

No

DK

If yes, how often?

Daily

Weekly

Occaisionally

Are currently experiencing dental pain or discomfort?

Yes

No

DK

Do you have earaches or neck pains?

Yes

No

DK

Do you have any clicking, popping, or discomfort in the jaw?

Yes

No

DK

Do you brux or grind your teeth?

Yes

No

DK

Do you have sores or ulcers in your mouth?

Yes

No

DK

Do you wear dentures or partials?

Yes

No

DK

Have you ever had a serious injury to your head or mouth?

Yes

No

DK

Date of your last dental exam:

What was done at that time?

X-Ray History:

Reason for dental visit today:

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?

Yes

No

If yes:

Have you ever been hospitalized or had a major operation?

Yes

No

If yes:

Have you ever had a serious head or neck injury?

Yes

No

If yes:

Are you taking any medications, pills, or drugs?

Yes

No

If yes:

Do you take a pre-medication prior to your dental appointment?

Yes

No

If yes, what is it, and for what reason

Do you take or have you taken, Phen-Fen or Redux?

Yes

No

If yes

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Yes

No

If yes

Are you on a special diet?

Yes

No

Do you use tobacco?

Yes

No

Women: Are you...

Pregnant or Trying to get pregnant?

Yes

No

Nursing?

Yes

No

Taking oral contraceptives?

Yes

No

Allergy Information

Are you allergic to any of the following?

Aspirin

Amoxicillin

Penicillin

Codeine

Acrylic

Metal

Latex

Sulfa drugs

Local Anesthetics

OtherOther

Do you use controlled substances?

Do you have, or have you had, any of the following?

AIDS / HIV Possitive

Yes

No

Alzheimer's Disease

Yes

No

Anaphylaxis

Yes

No

Anemia

Yes

No

Angina

Yes

No

Arthritis / Gout

Yes

No

Artificial Heart Valve

Yes

No

Artificial Joint

Yes

No

Asthma

Yes

No

Blood Disease

Yes

No

Blood Transfusion

Yes

No

Breathing Problems

Yes

No

Bruise Easily

Yes

No

Cancer

Yes

No

Chemotherapy

Yes

No

Chest Pains

Yes

No

Cold Sores / Fever Blisters

Yes

No

Congenital Heart Disorder

Yes

No

Convulsions

Yes

No

Cortisone Medicine

Yes

No

Diabetes

Yes

No

Drug Addiction

Yes

No

Easily Winded

Yes

No

Emphysema

Yes

No

Epilepsy or Seizures

Yes

No

Excessive Bleeding

Yes

No

Excessive Thirst

Yes

No

Fainting Spells / Dizziness

Yes

No

Frequent Cough

Yes

No

Frequent Diarrhea

Yes

No

Frequent Headaches

Yes

No

Genital Herpes

Yes

No

Glaucoma

Yes

No

Hay Fever

Yes

No

Heart Attack / Failure

Yes

No

Heart Murmur

Yes

No

Heart Pacemaker

Yes

No

Heart Trouble / Disease

Yes

No

Hemophilia

Yes

No

Hepatitis A

Yes

No

Hepatitis B or C

Yes

No

Herpes

Yes

No

High Blood Pressure

Yes

No

High Cholesterol

Yes

No

Hives or Rash

Yes

No

Hypoglycemia

Yes

No

Irregular Heartbeat

Yes

No

Kidney Problems

Yes

No

Leukemia

Yes

No

Liver Disease

Yes

No

Low Blood Pressure

Yes

No

Lung Disease

Yes

No

Mitral Valve Prolapse

Yes

No

Osteoporosis

Yes

No

Pain in Jaw Joints

Yes

No

Parathyroid Disease

Yes

No

Psychiatric Care

Yes

No

Radiation Treatments

Yes

No

Recent Weight Loss

Yes

No

Renal Dialysis

Yes

No

Rheumatic Fever

Yes

No

Rheumatism

Yes

No

Scarlet Fever

Yes

No

Shingles

Yes

No

Sickle Cell Disease

Yes

No

Sinus Trouble

Yes

No

Spina Bifida

Yes

No

Stomach / Intestinal Disease

Yes

No

Stroke

Yes

No

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